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INS,.RUCTIOI S
<br /> f' LMERGENCY Leak Bairns Con£zrmed - Leak suspected at site, but Inas not been confirmed.
<br /> indicate whether emergency response personnel and equipment were involved= Pre iminar Site Assessment Workrslan Submitted - workplan/proposal
<br /> ,ate
<br /> at any time If so, a Hazardous Material Incident Report should be filed requested of/submitted by responsible party to determine whether ground
<br /> with the State Office of Emergency,,Services (OES) at 2800 M- eadowview Road, 'water has been, or will be, im acted as a result of the release.
<br /> Sacramento, CA 95832, Copies of the OES,report farm may belobtained'at Pzeliti ar Site As essment Underuav - implementation of workplan_
<br /> your local underground storage tarx perni.tting agency. Indicate whether, Pollution Characterization - responsible party is in the process ,of fully
<br /> the OE S report has been filed as of the crate of this xexirrt. defining the extent of contamination in soil and ground water and assessing
<br /> impacts on surface and/or ground water,
<br /> LOCAL AGENCY ONLY Remediation Plan - remediation plan submitted evaluating long term
<br /> To avoid duplicate notification pursuant to Health and Safety code Section remediation options. Proposal and. implemantation schedule for appropriate
<br /> 25180.5, a government employee should sign and date the form in this block. remediation options also submitted.
<br /> A signature here does not mean that the leak has been determined to pose.a Cleanuxa Undarwa - implementation of remediation plan,
<br /> R significant threat to human health or safety, only that notification o rens - periodic ground water or other .
<br /> procedures have keen followed If roqcilred, monitoring at site, as necessary, to verify and/or evaluate effectiveness
<br /> of remedia3 activities,
<br /> RE-PORTED BY Case Cl- e9 - egio*nal board and local agency in concurrence that no
<br /> ''ter your name telephone number, and add ass. Indicate which party you further work is necessary at the site.
<br /> -present and provide company or agency naiz.e.
<br /> IMPORTANT: THE IP$l'OR1,1ATION PROVIDED ON THIS FORM IS INTENDED FOR. GF14ERAL
<br /> '
<br /> RESPONSTBP E Pfitl�L`<<" � S`IATZSTICAL P;IFPG�ES OPdT.Y A1�D IS IdOT TC I3E CON'TRt?ED AS P SEIaTIPTG THE
<br /> Enter_name, telephone number, contact person, and address of the party OFFICIAL POSITION OF A14Y GOVERNMENTAL AGENCY
<br /> responsible for the leak. The responsible pasty would normally be the tank
<br /> owner. REMEDIAL ACTION
<br /> h
<br /> Indicate which action have been used to clay ac p,or rcaradiate the leak_
<br /> SITE LOCATION Descriptions of options' follow:
<br /> Enter Information regarding the tank facility, At a minimum, you angst
<br /> provide the facility name and full address.
<br /> Ca Site _ install horizontal impermeable layer to reduce rainfall
<br /> infiltration.
<br /> IMPLEMENTING AGENCIES Containment Ba:ri.er - install vertical dike to block horizontal movement of
<br /> Enter names of the "local: agency and Regional `mater Qua ity Control Board contaminant.
<br /> involved. Excavate and 'L)spose - remove contaminated soil and dispose in approved
<br /> site,
<br />'
<br /> SUBSTANCES INVOLVED Excava � nd ;Teat remove contaminated soil and treat (includes spreading
<br />`
<br /> Enter the name and quantity _ost of the hazardous substance .involved. Rocco or land fawminf3
<br /> is provided for information on two substances of appropriate. If more than Remove Free Prcduc�. - remove floating product from water table,
<br /> two substancesleaked, list the two of most concern for cleanup. P+xn�rd rent Groundwater - generally employed to remove dissolved
<br /> on aminana,s_
<br /> DISCOVERY/ABATE EI�T Enhanced Biose radation - use of any available technology to promote� `
<br /> Provide information regarding the discovery and abateme,pt.of the leaky bacterial decomposition of contaminants.
<br /> Re lace Sian - provide alternative water supply to affected parties,
<br /> ttUBCE OA?JSE Treatment at F.00ku - install water treatment devices at each dwelling or
<br /> dicate source(s) of leak. Check box(es) indicating cause of leak. other place of use.
<br /> Vacuum Extract - use pumps or blowers to draw air through soil.
<br /> CASE TYPE Vent Soil - Bore 'noses in soil to allow volatilization of containinants,
<br /> indicate the ease type category for this leak. Check one box only. Case Pdo Action Heuired - incident is manor, requiring no remedial action.
<br /> type: is based on the most sensitive resource affected. For example, if
<br /> both sail and gi aurid cater have been a££ected, case type will be "Ground COMEN S Use this space to elaborate on any aspects of the incident,
<br /> Mater Indicate "Drinking Water--only if one or more municipal or
<br /> domestic water walls have actually been affected. A "Ground Water" SIGNATURE Sign the form in the space provided,
<br /> designation does not amply that the affected water cannot be, or is not,
<br /> used for drinking waters;but only that water wells have not yet been DISTRI£SUTION
<br /> affected. It is understood that case tyle- may change it on further _f the form is coring eted by the tank owner or his agent, retain the las:.,copy
<br /> snvest_ga ion, and forward the remaining copies intact to your local tank permitting agency
<br /> for distribution,
<br /> CURRENT STATUS I. Or_ginal. - Local Tank Permitting Agency
<br /> 1ndi.cate the category which best des cri.hes rhe, urrent status of the case. 2. State Water Resources Control- Board, Division of Clean Water Program5,
<br /> Check orne box only. The respoanse should be relative to.the-;case type. For Underground Storage Tank Program, P.C. Box 944212, Sacramento, CA 94244--
<br /> example, if case type is "Ground 'later" then "Current Status" should refer 2120
<br /> to the status of the ground water i:nvestig,,itior or cleanup,'as opposed to 3. Regional Cater Quality Control Board
<br /> th of soil, Descriptions of options fol.l.owr 4. Local Health 'Officer and County.Board of Supervisors or their designee to
<br /> receive Pzalosnlx ,rn5 tifications,
<br /> N 3cfToxn �Ien Ptc aetion leas b...-r .ti nn'by responsible party beyond 5, vw.ner1r_spoxsible par-"Y.
<br /> ins to a... _report t o Teak.
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